Provider Demographics
NPI:1679173025
Name:WILLIAMS, VICTORIA
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:LANATT
Other - Last Name:PEWITTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:853 N HIGHLAND AVE STE C
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-2218
Mailing Address - Country:US
Mailing Address - Phone:224-210-2215
Mailing Address - Fax:
Practice Address - Street 1:853 N HIGHLAND AVE STE C
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-2218
Practice Address - Country:US
Practice Address - Phone:224-210-2215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILW452-86083965172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver